title: Protocol for a randomised controlled trial of treatment of asymptomatic candidiasis for the prevention of preterm birth [ACTRN12610000607077].
abstract: BACKGROUND
  Prevention of preterm birth remains one of the most important challenges in maternity care. We propose a randomised trial with: a simple Candida testing protocol that can be easily incorporated into usual antenatal care; a simple, well accepted, treatment intervention; and assessment of outcomes from validated, routinely-collected, computerised databases.
  
  
  METHODS
  Using a prospective, randomised, open-label, blinded-endpoint (PROBE) study design, we aim to evaluate whether treating women with asymptomatic vaginal candidiasis early in pregnancy is effective in preventing spontaneous preterm birth. Pregnant women presenting for antenatal care<20 weeks gestation with singleton pregnancies are eligible for inclusion. The intervention is a 6-day course of clotrimazole vaginal pessaries (100 mg) and the primary outcome is spontaneous preterm birth<37 weeks gestation.The study protocol draws on the usual antenatal care schedule, has been pilot-tested and the intervention involves only a minor modification of current practice. Women who agree to participate will self-collect a vaginal swab and those who are culture positive for Candida will be randomised (central, telephone) to open-label treatment or usual care (screening result is not revealed, no treatment, routine antenatal care). Outcomes will be obtained from population databases.A sample size of 3,208 women with Candida colonisation (1,604 per arm) is required to detect a 40% reduction in the spontaneous preterm birth rate among women with asymptomatic candidiasis from 5.0% in the control group to 3.0% in women treated with clotrimazole (significance 0.05, power 0.8). Analyses will be by intention to treat.
  
  
  CONCLUSIONS
  For our hypothesis, a placebo-controlled trial had major disadvantages: a placebo arm would not represent current clinical practice; knowledge of vaginal colonisation with Candida may change participants' behaviour; and a placebo with an alcohol preservative may have an independent affect on vaginal flora. These disadvantages can be overcome by the PROBE study design.This trial will provide definitive evidence on whether screening for and treating asymptomatic candidiasis in pregnancy significantly reduces the rate of spontaneous preterm birth. If it can be demonstrated that treating asymptomatic candidiasis reduces preterm births this will change current practice and would directly impact the management of every pregnant woman.
  
  
  BACKGROUND
  Australian New Zealand Clinical Trials Registry ACTRN12610000607077.
authors.affiliation: Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, Department of Obstetrics and Gynaecology, University of Sydney, and Royal North Shore Hospital, NSW Australia. clroberts@med.usyd.edu.au
authors.forename: Christine L
authors.initials: CL
authors.lastname: Roberts
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Morris
authors.forename: Kristen R
authors.initials: KR
authors.lastname: Rickard
authors.forename: Warwick B
authors.initials: WB
authors.lastname: Giles
authors.forename: Judy M
authors.initials: JM
authors.lastname: Simpson
authors.forename: George
authors.initials: G
authors.lastname: Kotsiou
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Bowen
mesh_terms: D000935:Antifungal Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D001315:Australia; D002175:Candida / Q000302:isolation & purification; D002181:Candidiasis, Vulvovaginal / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D002985:Clinical Protocols; D003022:Clotrimazole / Q000008:administration & dosage / Q000627:therapeutic use*; D005260:Female; D005865:Gestational Age; D006801:Humans; D057194:Intention to Treat Analysis; D011247:Pregnancy; D011261:Pregnancy Trimester, First; D011262:Pregnancy Trimester, Second; D047928:Premature Birth / Q000209:etiology / Q000517:prevention & control*
chemical_list: D000935:Antifungal Agents; D003022:Clotrimazole